Prophylaxis Against Venous Thromboembolism After Total Hip and Knee Arthroplasty A Critical Analysis Review

Clinical practice guidelines from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) and a clinical effectiveness literature review from the Agency for Healthcare Research and Quality (AHRQ) are in agreement about the need for active intervention in preventing venous thromboembolism after total hip arthroplasty or total knee arthroplasty, but a paucity of clinical end-point data provide no basis for the endorsement of any specific regimen over another. The adjunctive use of mechanical compression devices is associated with a reduction in venous thromboembolism and no incremental bleeding risk, but data are not sufficient to recommend the use of mechanical compression devices as the sole means of venous thromboembolism prophylaxis at this time. Warfarin remains popular among North American surgeons for venous thromboembolism prophylaxis, largely because of its delayed onset of action and correspondingly low bleeding risk. However, it is not an ideal option because of the need for monitoring and unpredictable drug sensitivity in some patients that can result in occasional bleeding complications. Newer anticoagulants are very specific and more potent in their actions. They are highly effective in reducing deep venous thrombosis, but have not resulted in a meaningful decrease in clinical pulmonary embolism and are accompanied by a substantial increase in major and non-major clinically important bleeding. Recent observational data on aspirin prophylaxis suggest rates of clinical pulmonary embolism that are comparable with those observed with more potent anticoagulants, particularly when used in combination with regional anesthesia and pneumatic compression devices. The optimal regimen for the prevention of clinically important deep venous thrombosis and pulmonary embolism remains to be identified. Available evidence does not identify a clearly preferred best practice. A large pragmatic clinical effectiveness trial is warranted.